How to Manage an Eczema Flare Up

In honour of National Eczema Week in September, we decided to share some simple advice on how to deal with eczema flare ups, particularly at a time when frequent handwashing and mask wearing can exacerbate existing skin issues.

What is eczema?

Eczema (also known as atopic dermatitis) is a chronic skin condition that is usually characterised by itchy, red, and inflamed skin. While eczema can be well-managed and symptoms kept to a minimum, a flare up is characterised by a sudden increase in its severity. The itchy, red skin can weep, blister, and scale. It can also get infected.

What causes it? 

Eczema is a very complicated condition. However, the root problem lies in a dysfunction of the normal skin barrier. The disruption of the barrier makes the skin more vulnerable to dehydration, irritation, and infection.

Eczema is in a group of conditions we call “atopic,” which includes asthma and hayfever. There is a genetic component to eczema, and it often runs in families.

 Flare-ups are usually caused by a specific environmental trigger that exacerbates the underlying condition and irritates the skin. There are a few well-known triggers, which include soaps and detergents, synthetic fibres, and heat.

 What are a few things someone can do if they are having a flare up? 

The first thing to do is try to see if you can identify the trigger for the flare up. This can be done in discussion with a medical professional, who will know what targeted questions to ask you. Always consider if you have made a recent change to things that have frequent contact with your skin. Have you started using a new soap or detergent? Are you wearing a new perfume, or are you wearing a new type of clothing? Has there been any recent change to your environment? Eczema can be triggered by sweating, hot climates, animal hair, and pollen. And always think about your diet.

The treatment for a flare up depends on its severity. However, in general, generous use of moisturising emollients are recommended. Emollients help form an occlusive barrier over your skin, locking in moisture, maintaining the skin barrier, and protecting your skin from irritants. Emollients can be applied every 2-3 hours, and you should always feel comfortable applying more if needed. You probably want to avoid emollients that have active ingredients in them, as these can cause a further reaction or irritation to the skin. Ideally, your emollient should be in a pump dispenser to reduce the risk of bacterial contamination and infection. If it is in a tub, use a spatula to remove the cream or ointment rather than your fingers. However, there is no “one-size-fits-all” solution, and you can be guided by doctor to find the right emollient for you.

If you are suffering a more severe flare up, always go to see your doctor to be assessed and prescribed any extra treatments as appropriate. If your skin is severely inflamed, you might benefit from a prescription of a short course of topical corticosteroids. Similarly, if there is extreme itchiness, a short course of antihistamines could be helpful. Any evidence of an infection should be treated by your doctor.

The same general principles apply to eczema on the face as eczema anywhere else: the cornerstone of treatment is to moisturise with frequent emollient use and protect that precious skin barrier. However, the skin of the face is more sensitive and delicate, and prescription treatments are used more sparingly and carefully on the face. If you need a steroid cream, this should be under the guidance of your doctor. You will be given a milder steroid at a smaller dose for the skin on your face in comparison with the skin on the rest of your body.

Avoid complementary therapies like homeopathic remedies, herbal medicine, or essential oils. These have not been proven to be effective in any clinical trials, and often can actually have negative consequences and worsen your skin. If you are trialling any unproven methods, always inform your doctor so they are aware and can make sure you are not prescribed anything that might interact with any other treatments you are taking.

Any specific skin care ingredients to use and any to avoid? 

The most important thing to do is promote repair and healing of your skin barrier. There are a few skincare ingredients that can be very helpful in eczema. Ceramides are lipids found naturally in the top layer of your skin, and topical application can help improve the integrity of your skin barrier. Moisturisers containing urea or glycerol can also be helpful in acting as humectants, which increase the water content of the skin. Paraffin (also known as petroleum jelly) can be another helpful ingredient, as it helps form a waterproof barrier over the skin.

Soaps, detergents, and foaming agents can irritate eczema. These should be avoided during a flare-up, as they can cause further disruption to the lipid barrier of the skin. Some patients also find that products with fragrances will make their skin worse. Actives in skincare (like retinol) can really irritate the skin, and shouldn’t be incorporated into your skincare routine without advice and guidance from a professional.

Aqueous creams are not recommended, as these tend to cause a high rate of skin reactions.

What does a typical skin care routine looks like for someone with eczema? 

The best thing to do is keep your skin routine simple and gentle if you are prone to frequent flare ups on the face. Use a gentle, non-foaming cleanser that won’t strip away the natural lipids on your skin, further disrupting the skin barrier. Eczema is very sensitive to heat, so using cool or lukewarm water is completely appropriate when cleansing.

As I’ve already emphasised, hydrating your skin is the key to managing your eczema, so choose a nice, fragrance-free, emollient.

Try to keep makeup to a minimum, as makeup is another frequent trigger of skin irritation. The impulse to cover up any redness can be a double-edged sword, as it often makes your skin worse. If you do wear makeup, avoid harsh makeup-removing wipes as these can often contain alcohol which dries out the skin. Remove makeup with something gentle, like micellar water.

Limit your exposure to UV radiation, as this can trigger or worsen an eczema flare. We should all always be wearing SPF of at least 30 or above, but it is especially important for those who suffer eczema on their face. Those with sensitive skin often find physical sunscreens easier to tolerate than chemical ones.  

What about all this frequent handwashing and sanitising? 

In the current COVID-19 pandemic, good hand hygiene is the cornerstone of protecting yourself and others from spreading infection. Unfortunately, we know that soap can be a trigger for eczema. Even those with less-sensitive skin can find the frequent handwashing extremely harsh on their skin.

In normal circumstances, an ointment or lotion dissolved in warm water has been suggested as a suitable soap substitute for eczema sufferers. However, the British Association of Dermatologists have updated their guidance in response to the COVID-19 pandemic, and emphasise the importance of using soap in handwashing.

After washing, pat your hands dry gently, avoiding any rubbing that could cause chafing and soreness. Generous application of moisturising hand lotion after washing can help ease any discomfort. I would recommend keeping a portable tube of moisturiser on-hand.

It would seem intuitive that handwashing is preferred over hand sanitiser, as the sanitiser feels like it has a harsher, more drying effect on eczema-prone skin - alcohol stings! However, believe it or not alcohol gel is less irritant overall because the detergents in soap are what will strip away your lipid barrier, doing more damage to the stratum corneum. Hand sanitiser with alcohol content over 70% is effective in killing enveloped viruses, like COVID-19. Unfortunately, you should always prioritise cleaning your hands during this pandemic over the possible discomfort to your skin.

Any specific recommendations with regards to face mask wearing? 

We know that sweat and heat are often triggers for eczema flares, so wearing a constricting or heavy mask over your face can therefore make your skin worse. However, remember that general mask-wearing in public is more about protecting others than ourselves, as we are trying to minimise any particulate matter from escaping our mouths and noses into the environment. This is different from a healthcare setting, where healthcare workers need to wear very specific types of masks to protect themselves when in close contact with known COVID patients. For general use, you can make your own masks at home. Use the gentlest, softest fabrics available – especially if you know what your skin can already tolerate well.

Make sure that you have a few masks, so that you are able to wash the masks between uses. There is nothing more irritating to your skin than re-wearing a dirty mask over and over again, not to mention the risk of bacterial skin infection.